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Issues Management Guide
To support countries in preparing for
unexpected situations with implications for
public communications
October 2014
Contents
1. Purpose of this document ............................................................................................................... 2
2. Introduction .................................................................................................................................... 2
3. Rationale for OPV cessation and IPV introduction ......................................................................... 3
4. Determining whether to respond or communicate ........................................................................ 5
5. Best practices for developing a plan ............................................................................................... 5
6. Developing key messages ............................................................................................................... 8
7. Standard procedures for reactive issues management .................................................................. 9
Annex: Example of a reactive communication strategy ...................................................................... 12
For further information on IPV introduction, the OPV switch and routine immunization strengthening:
http://www.who.int/immunization/diseases/poliomyelitis/inactivated_polio_vaccine/en/
Please send any questions or feedback on the materials to: [email protected]
All materials available through this web site are the product of an extensive collaboration between WHO, UNICEF, the Task Force for Global Health, CDC, Gavi, Rotary, and the Bill and Melinda Gates Foundation,
organized under the Immunization systems Management Group (IMG).
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1. Purpose of this document
This resource document is intended to support countries in preparing for unexpected situations in
relation to 1) the introduction of inactivated polio vaccine (IPV) and 2) oral poliovirus vaccine (OPV)
withdrawal which may require a public communications response. It is intended to be used as a
resource in helping identify an unexpected situation, evaluate its potential impact, and develop an
appropriate communications strategy in response to minimize potential fall-out (e.g. affecting
confidence in immunization in general or IPV specifically).
Unpredictable, unexpected events happen – frequently they are marked by uncertainty, confusion
and a sense of urgency. Such events can lead to lack of trust – in organizations, people or
immunization services. Having a pre-prepared communications plan in place can help minimize the
potentially negative impact of such events.
2. Introduction
Objective 2 of the Global Polio Eradication Initiative’s (GPEI) Polio Eradication and Endgame Strategic
Plan 2013-2018 calls for the introduction of at least one dose of inactivated polio vaccine (IPV) into
routine immunization systems in preparation for the phased removal of oral polio vaccines (OPV).
The introduction should be viewed as an opportunity to strength routine immunization (RI)
programmes.
Countries currently using OPV only are in the process of putting in place IPV introduction plans, to
ensure this vaccine can be introduced into national routine immunization programmes in 2015,
ahead of the planned start of the phased removal of OPVs in 2016.
As part of introductory plans, proactive communications and social mobilization activities may be
implemented at country and sub-national levels to ensure that identified target audiences are
informed about IPV introduction as part of the RI programme. Key audiences include policy makers,
medical professionals, health workers, parents and local caregivers. Communication plans should be
prepared to address questions and concerns related to IPV, trivalent OPV, bivalent OPV and actual or
potential adverse events following immunization (AEFIs). Bivalent OPVs will be replacing trivalent
OPV as part of the phased removal of OPV.
Additionally, countries must be prepared to address potential unexpected ‘negative’ events around
IPV introduction and OPV cessation. This document identifies examples of scenarios that may
require a rapid communication response, effective practices for AEFI communications, and examples
of standard operating procedures (SOPs) around potential reactive communications issues
management.
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3. Rationale for OPV cessation and IPV introduction OPV is safe and effective at protecting children against lifelong polio paralysis. Over the past ten
years, more than 10 billion doses of OPV have been given to nearly three billion children
worldwide. More than 10 million cases of polio have been prevented, and the disease has been
reduced by more than 99%. It is the appropriate vaccine through which to achieve global polio
eradication.
OPV contains attenuated (weakened) polioviruses. On extremely rare occasions, use of OPV can
result in cases of polio due to vaccine-associated paralytic polio (VAPP) and circulating vaccine-
derived polioviruses (cVDPVs). cVDPVs are vaccine viruses, which through circulation in susceptible
populations have mutated and regained the transmissibility and virulence properties of wild polio
viruses (WPVs). VAPP is a very rare vaccine adverse event in which the oral vaccine causes paralytic
polio in the vaccine recipient or a close contact. Because of VAPP and cVDPVs, the global eradication
of polio requires the cessation of all OPV in routine immunization as soon as possible after the
eradication of wild poliovirus transmission. Since VAPP is rare and not widely transmissible, some
countries have chosen not to focus discussions around VAPP, instead focusing on cVDPVs which
have more of an impact on the public at large.
OPV is available in different formulations:
Trivalent OPV – containing type 1, 2 and 3 serotype
Bivalent OPV – containing type 1 and 3 serotypes
Monovalent OPV – containing one serotype (i.e., type 1, 2 or 3)
A mix of all formulations is used to eradicate polio during supplementary immunization activities
(SIAs). Trivalent OPV is the only formulation used in routine immunization programmes. Bivalent
OPV is the most widely-used formulation during SIAs to more rapidly interrupt the remaining strains
of WPV1 and WPV3 transmission – the only remaining WPV strains in circulation. WPV2 has been
eradicated since 1999.
With WPV2 transmission already successfully interrupted, the only polio cases caused by the type 2
serotype are those related to the type 2 component of trivalent OPV. Over 90% of cVDPV cases are
due to mutations in the type 2 component of the vaccine, which is also responsible for up to 38% of
VAPP cases. This why routine immunization programmes will switch from trivalent OPV to bivalent
OPV – even before WPV1 and WPV3 transmission are stopped. Following WPV1 and WPV3
eradication, use of all OPV in routine immunizations will be stopped.
To minimize the risks associated with the phased removal of OPV, countries must adequately
prepare for the eventual switch from trivalent OPV to bivalent OPV (followed by the cessation of all
OPVs altogether). The primary risk associated with the switch will be the increase in susceptibility to
poliovirus type 2 in the population, which in turn would increase the risk of the emergence of cVDPV
type 2 in the immediate period following withdrawal of trivalent OPV. Safely managing this risk will
be key to a successful switch from trivalent to bivalent OPV.
To maintain immunity levels to type 2 polio, all countries should introduce at least one dose of IPV
into routine immunization programmes by 2015, as recommended by the Strategic Advisory Group
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of Experts on immunization (SAGE). IPV mitigates or reduces the risk of cVDPV because it is a
trivalent vaccine and uses inactivated, rather than weakened, viruses. IPV also strengthens the
immune response to types 1 and 3. After the switch from trivalent to bivalent OPV, IPV will be the
only vaccine with which to maintain immunity to type 2 polio.
Scenarios: Examples of situations where issues management may arise
There are a number of events related to IPV, IPV introduction and OPV withdrawal that could
negatively affect a vaccination program and that may require a communication response and rapid
provision of information. Listed below are some of the scenarios that could arise.
Scenario Description of scenario
Wild polio cases or detection of wild polio viruses in a country or community
It is possible that after a country introduces IPV that wild polio viruses may be detected (e.g. in environmental surveillance) or that there may be a case or outbreak of polio in the country. It can be important to communicate that while IPV is an important vaccine for achieving polio eradication, the vaccine cannot prevent polioviruses from coming into a country. In the event of significant polio transmission in the post-eradication era, mOPV will be the vaccine of choice in trying to end transmission.
IPV vaccine supply shortages or delays
It is always possible that there can be shortages or delays in the availability of vaccines, including IPV. Even with the best planning, manufacturing or shipping delays, for instance, there could be temporary shortages or delays in the availability of IPV in some places. If there is or is going to be an IPV supply shortage or delay, it is often best to communicate that as soon as possible.
OPV-associated polio Very rarely, OPV vaccine can cause polio – this is one of the reasons for the transition to IPV. If a country or community has not experienced or is not aware of vaccine-associated paralytic polio (VAPP) it could be alarming. It can be helpful to provide information in advance on vaccine-associated polio, including letting the medical community know that it is rare.
Other real or potentially associated vaccine adverse reactions
Immunization can be followed by an adverse event (AEFI), which can be caused by the vaccine or by an error in the immunization process. It is also possible that people will believe a reaction was caused by a vaccine when it was not. Given the wide use of vaccines, coincidental health problems not caused by the vaccine could be blamed on the vaccine because the adverse event closely follows the vaccination in time. Uncertainty and fear about vaccine adverse events can quickly harm an immunization program so it is very important to communicate quickly should an AEFI occur. In the event of an AEFI, tell people what is known and what is being done to investigate and respond. It is also often helpful to be proactive to let local officials know what to expect (e.g., reports of AEFIs may occur and that they are likely to be coincidental but a full investigation will be done).
A new study or experimental data involving IPV
New research about the benefits of vaccines is being published all the time. There can be a need to communicate when such research receives news media or public attention. Most research does not generate attention, but if the research involves vaccine safety there can be a need to communicate quickly.
Activist criticisms or claims designed to stop introduction or decision to introduce IPV or criticize global involvement
There are many claims an activist could make and steps they could take to slow or stop IPV introduction. Tactics that have been used include asking questions in parliament, bringing about a court case or otherwise blocking progress of introduction. Agreement amongst country and global stakeholders on a protocol for responding or not should be discussed prior to IPV introduction.
A report in the news media or local rumour regarding IPV or OPV
The media often has articles about vaccine safety or concerns that can grab public or parent attention. Often the stories involve anecdotes or unsupported claims. If the claim will reduce or harm public or parent confidence in IPV, there may be a need to respond or reassure the public.
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Temporary suspension of an IPV or OPV vaccine
Temporary suspensions of a vaccine from public use, including in another country, can cause public attention and concern, particularly among individuals who were recently immunized or were planning to be immunized. In the case of IPV or OPV, it would be helpful to communicate quickly, including the reasons for the suspension and any public health advice to parents whose children were recently vaccinated.
An IPV or OPV vaccine recall
Very rarely, manufacturers may have to recall a vaccine for safety reasons. Recalls are often broadly publicized and therefore a communication response is often needed from public health officials. As with a temporary suspension, it will be important to provide information and guidance to parents and caregivers.
4. Determining whether to respond or communicate
When an immunization programme becomes aware of an event involving or affecting IPV or OPV
vaccination, it must decide whether to communicate this information, how the information should
be communicated, and with which groups and people to communicate. It also needs to decide what
the public health messages and guidance will be. When programmes inform health workers, the
media, parents or the public about an issue involving a recommended vaccine, it is important to
identify 1) why the information is being provided and 2) what should be done as a result of the
information.
Whether real or perceived, any vaccine related event can become a crisis situation if it is not handled
correctly. Informing health workers, the media, parents or the public in a timely manner can help
maintain confidence in the vaccine and the immunization recommendation. Not promptly disclosing
a potential problem can reduce trust and confidence and cause parents to delay vaccination.
In determining how and when to respond and communicate about an IPV-related event, below are
some guidelines to consider. Immunization programme managers should also consider whether the
event will have a low, medium or high impact or risk to public health and/or the immunization
programme. Many events will be low impact if public health and immunization programs proactively
address the issue before an actual event happens. For example, training health workers to expect
stories and reports of adverse events following immunization or for the possibility of wild polio cases
even after IPV is introduced.
5. Best practices for developing a plan Unexpected vaccine-related events are frequently marked by uncertainty, confusion and a sense of
urgency. Effectively communicating around such events, including through mass media, can help
minimize their impact, and can help maintain trust and confidence in organizations, persons or
services (such as immunization). Key elements of conducting a ‘best practice’ communications
approach to such events are summarized below. All are aimed at securing trust - the overriding goal
in issues management communications is to help build, maintain or restore trust. Consequences of
losing the public’s trust can be severe, in particular around public health issues.
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Advance preparation
is critical! An issues management
plan should be developed in advance of a vaccine
introduction, ready to be adapted if an event occurs.
Timing of public announcements
The timing, candor and comprehensiveness of a public
announcement are critical, and may be the most important aspect
of issues management communications. This is particularly critical
given today’s globalized, internet-connected world, where
information can rapidly be transmitted in an uncontrollable manner.
It is important that key internal partners are informed ahead of a
public announcement.
Transparency
Communications should be conducted in an easy-to-understand, complete and factually accurate
manner. As and when new and relevant information becomes available, this information should also
be subsequently communicated.
Know your target audiences
Clearly identifying with whom you want to communicate and understanding their concerns, will help
ensure that the right messages are delivered by the right messengers through the right channels.
This will enhance the impact of the message delivery.
Empathy and acknowledgement of the audience’s concerns
As applicable, communications should be suitably understanding and compassionate in
acknowledging and responding to the issue or event. It often helps to begin with acknowledging that
people are concerned or have concerns
Planning
Communications should be an integral strategic part of the broader technical issues management
control. Having a pre-prepared communications plan in place and trained spokespeople are key.
Sensitizing the media in advance of an unexpected event can also be helpful, not only for the
introduction of a new vaccine but also for understanding the contribution vaccines make to the
health and well-being of children and the country overall.
Monitoring of evolving situation
Monitoring and continually evaluating the situation will aid in further sensitizing and targeting a
communications approach over time.
Guidelines to consider
Learn and Confirm - The first step is to identify and confirm what has happened or what has been
claimed to have happened. People will want to know the facts and it is important to be sure you
have the correct information before you begin communicating.
Designate a spokesperson – Identify a person to serve as the primary spokesperson for
communicating with the media and public. This person should be known to be credible and
trusted, have knowledge on the subject, and be prepared to communicate with the media.
If in doubt, communicate – From a public and health worker trust standpoint, it is better to err
on the side of too much communication, than too little.
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Provide regular updates – It can help to provide frequent updates to health workers, the media
and the public, especially if the event affects whether or when IPV or OPV are given.
Let media and public know if you “don’t know” – In the early stages of a vaccine-related event
you likely will not have all the information and details. It can be helpful to let the public and
media know that you do not currently have all the information needed. It is also important to let
them know you are working on getting more information and to provide an idea of the time line.
Be flexible and ready to take more or new action if events that initially seemed to have low
impact on the vaccine programme suddenly change to medium or high impact.
Be proactive with positive placements about the value of vaccines and the polio plan. This will
help counterbalance negative media and help reduce the credibility and importance of negative
reports, especially those that involve anecdotes or unsupported claims.
Adverse Events Following Immunization (AEFIs): Essentials
Simplify complex information – communicate in a way that everyone can understand.
o Note that fear and anger are barriers to effective communication.
Communicate early and often to health workers about the situation. Health workers need to be
confident in vaccines and vaccination recommendations. They are also the people who will be
talking with parents and caregivers. The medical community, including pediatricians, should be
considered as they are often those speaking with the media and providing advice to parents.
Listen to what the public or parents are saying and try to understand their concerns and the
underlying reasons for their concerns. This includes understanding the local perception of the
disease, perception of injections and perception of the vaccine.
Be as transparent as possible and proactively outline steps taken by the government to
strengthen routine immunization alongside the introduction of IPV.
If an AEFI occurs, communicate as quickly as possible. The public needs to know that you share
their concerns, that the situation is being investigated and that you will keep them informed.
Make sure that all partners are giving out the same message, but tailor explicit communication
messages to the specific situation. It is useful to differentiate between the general public and
the medical community and their respective information needs.
Risks perceived to be generated by a trusted source are more accepted than risks perceived to
be generated by an untrusted source, so have a trusted spokesperson deliver the message and
be cautious about trying to discredit others. It is often best to take a positive approach and
perpetuate a dialogue over unfounded or unsupported claims.
Risks perceived to have clear benefits are more accepted than risks perceived to have little or
no benefit. It is important to make sure families and communities understand the benefits and
importance of vaccination.
Risks perceived to be familiar and understandable are more accepted than risks perceived to
be exotic. Avoid technical terms and long words or phrases when explaining.
Identify and meet the needs of the media. Media can be the gateway to public opinion. Also
remember that many or most journalists may not understand: 1) why vaccines are used; 2) how
vaccines work; and 3) the difference between a report or claim of an adverse event following
immunization and an actual or verified adverse event – many or most reporters may assume
that if there is a report that it must be true that the vaccine caused the outcome.
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6. Developing key messages
Key messages are short statements designed to communicate essential information and points to
the public, news media, or health workers. They reflect the essential information you want to
convey and can also function as “sound bites” during media interviews. It is helpful to have
developed key messages prior to communicating about vaccine-related events. Having key
messages prepared in advance will allow you to communicate quickly and effectively.
Points to consider when developing key messages:
List the 3-4 things you really want health workers, the public or the media to know, to
consider, or to think about.
Ensure the key messages:
o Are specific, clear and concise
o Use word and examples that your audience will understand
o Avoid jargon and technical terms
o Are positive – talk about what you are doing, and can and will do; not what you cannot
Identify who is affected and let people know how they can determine if they were affected
(e.g., by identifying the places and dates)
Show compassion for anyone impacted by the event, even if there is no link to the vaccine
Address the cause or potential cause of the event
Provide guidance about what to do or what should be done going forward
Messaging for an example scenario:
Contamination of multi-dose vials of IPV
See below some examples of key statements that could be used with the public or media to inform
them about a contamination of multi-dose vials of IPV:
We (health officials in country) learned yesterday that a number of vials containing IPV vaccine
at a local clinic were found to have bacteria in them. [Note: if you can provide number do so]
The problem was discovered after (three) children who received IPV vaccine at the clinic
became ill. The children were vaccinated on (provide date).
We are working to check on all the children who have received IPV vaccine at this clinic since
(provide date). We want to know if they got ill and if so, how they are doing.
The (three) children who received the bad IPV vaccine are (current health condition).
Vaccine safety is very important and we are investigating this fully. We are also taking steps to
make sure all clinics are properly handling and using IPV vaccines.
We will make sure that all IPV vaccine given at this clinic is safe. To do that, we are (list the
actions being taken).
It is important to note that only IPV vaccines received at this clinic were affected. Other
vaccines were determined not to be affected. We have no reports or concerns with IPV or
other vaccines being provided at other clinics.
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7. Standard procedures for reactive issues management
1. Establish a core communications team:
Consisting of communications professionals in relevant partner agencies (e.g., WHO, UNICEF,
GAVI, Rotary, and within the ministry of health - MoH)
The core communications team will liaise closely with technical counterparts in evaluating
potential unexpected negative news or issues that may arise, and plan and implement an
appropriate communications response, as necessary. Technical counterparts may include
independent experts, pediatric associations, academicians as well as government and partners.
The team may also determine that proactive media training for spokespeople and/or journalist
training is beneficial and should be included in response plans.
Determine timelines or schedules for providing information and situation updates.
Identify the sources of resources and capacity that may be needed to support the development
and implementation of a issues management plan
2. Evaluate the situation:
The core communications team, in liaison with technical counterparts should:
Assess the situation and its potential impact (i.e., reputational management issue, issue with
vaccine safety or supply, epidemiological issue, political or societal issue, adverse event
following immunization - AEFI)
Evaluate the extent of news coverage and interest (i.e., one article, or extensive secondary
media pick-up)
Determine ‘geographic’ impact (i.e., subnational, national, regional, global)
3. Determine actions:
The core communications team, in liaison with technical counterparts:
Based on situation evaluation, should develop a reactive communications action plan strategy as
necessary, in conjunction with technical counterparts as appropriate. (See ‘annex’ for example
of a draft plan.)
This may require collaboration with regional and global teams, as necessary and appropriate.
Particular focus will be on ensuring potential political sensitivities are taken into account, and
that partners are informed prior to dissemination of information to the public domain.
Examples of items to consider when evaluating if an issue requires or would benefit from a
communications response (and scale of response) include:
Can the issue have significant potential fall-out, i.e. affect confidence in immunization, in IPV, or
in the Ministry’s ability to deliver services?
Who is most likely to be affected by this issue? Parents, communities, medical professionals,
partners, donors, the government
What type of messages might they need? For example, key messages on safety of IPV such as:
o IPV is a safe vaccine, whether used alone or in combination vaccines
o IPV vaccine has not been associated with any serious adverse events in [the country]
o Minor side effects include minor local reactions such as pain and redness at injection site
o IPV has been used extensively around the world for more than 60 years
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o Strong and rigorous quality control standards are in place to ensure the safety of IPV
Consider proactive communication
o Positive communications about the impact of immunization or stories about the
introduction with well-informed journalists can help build support for immunization and
the introduction of IPV
o Spokesperson and journalist training should be considered
o Providing information and stories to trained journalists can help ensure more balanced
reporting should an incident arise
4. Steps in producing materials:
Agree who will take lead in producing which materials
Develop initial draft
Share with relevant technical counterparts to ensure technical accuracy
Share with broader core communications team for input
Finalize draft and circulate for internal approval as appropriate
Translate into local/other languages as necessary
5. Monitor evolving situation:
Establish clear mechanisms and systems to monitor the evolving situation, and to evaluate the
impact of communications activities, including over time (i.e., media monitoring, assessments of
views among key target audiences, etc.)
Adapt and further tailor the communications strategy based on outcomes
Resources to consult as a guide:
A number of communications resources have been developed at global and regional level, to
support countries in their IPV introduction and OPV cessation plans. These include:
Vaccine safety events: managing the communications response. A Guide for Ministry of Health, EPI
Managers and Health Promotion Units. WHO Regional Office for Europe, 2013.
http://www.euro.who.int/__data/assets/pdf_file/0007/187171/Vaccine-Safety-Events-managing-
the-communications-response-final.pdf?ua=1
World Health Organization: Adverse Events following Immunization -
http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-
immunization/vaccines-and-immunization/learn-more-about-vaccines/vaccine-quality-and-
safety/adverse-events-following-immunization-aefi
Building Trust and Responding to Adverse Events following Immunisation in South Asia: Using
Strategic Communication, United Nations Children’s Fund, Regional Office for South Asia, Working
Paper, 2005 http://www.unicef.org/rosa/Immunisation_report_17May_05(final_editing_text).pdf
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For more information, please contact:
WHO
Oliver Rosenbauer
Communications Officer – Global Polio
Eradication Initiative
WHO Geneva
Tel +41 22 791 3832
Lisa Menning
Technical Officer – Immunization, Vaccines and
Biologicals
WHO Geneva
Tel +41 22 791 1493
UNICEF
Gaurav Garg
Regional Immunization Communications
Officer
UNICEF South Asia
Tel +977 9818016649
Ben Hickler
Communications Officer
UNICEF New York
Tel +1 917 265 4613
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Annex: Example of a reactive communication strategy
Development of objectives:
Clearly identify and state the aims the communications strategy will seek to achieve.
Identification of target audiences:
Internal audiences, e.g. national and sub-national staff in partner organizations and Ministries
Professional audiences, e.g. NITAGs, paediatric associations, medical doctors, nurses
Broader audiences, e.g. health workers, communities, parents
Media, e.g. general media, scientific media
Development of key messages:
Tailored towards each target audience’s needs, concerns and likely questions
Identification of spokespersons and training on messaging as appropriate:
Partner agency and Ministry spokespersons, independent experts, caregivers and parents
Monitoring of impact:
As necessary, based on the evolving situation, additional activities may be implemented to ascertain
the impact of the issue, such as: knowledge, attitudes and practices (KAP) evaluations among
specific audiences (caregivers, communities, parents, medical professionals, etc.)
Project management example for implementation of activities:
Successful implementation of activities can be assured through effective project management. A
simple table can help in this process, as outlined below.
Activity Status Next steps Responsibility Date
Internal staff
briefing
-Book meeting room
-Invitations to all
staff sent out
-Speakers identified
and invited
-Brief speakers
-Prepare talking points and
PowerPoint slides
-Ensure AV support
available
Lucas, UNICEF 15 Feb
Fact sheets
and reactive
Q&As
-Initial draft
developed
-Forward to technical
colleagues to ensure
accuracy
-Share with partner focal
points for input
-Finalize incorporating
comments
-Post on website and
distribute to key partners
Maria, WHO 20 Feb
Etc… Etc… Etc… Etc… Etc…
